maternal and child health bureau seminars on adolescent health: nutrition and physical activity,...

Maternal and Child Health Bureau

Seminars on Adolescent Health:Nutrition and Physical Activity,

Part IJuly 30, 2003

Health Resources and Services AdministrationMaternal and Child Health Bureau

Moderator: Trina Menden Anglin, M.D., Ph.D., Chief, Office of Adolescent Health

The Obesity Epidemic Among Youth in the United States:

Causes and Prevention

Steven Gortmaker, Ph.D.

Harvard School of Public Health

Overview

• A brief overview of the magnitude and rapid growth of the obesity epidemic among youth

• The fundamental causes of the epidemic

• Why industries generating the obesity epidemic find it in their interest to continue their work

The Problem:

• Obesity is increasing rapidly among children, youth and adults in the US

• Increases are found in all regions of the country, urban/rural, both sexes, all ethnic groups, rich and poor

Obesity Trends* Among U.S. AdultsBRFSS, 1990

(*BMI 30, or ~ 30 lbs overweight for 5’4” woman)

No Data <10% 10%-14% 15-19% 20%

Source: Mokdad AH.



No Data <10% 10%-14% 15-19% 20%

Source: Mokdad AH.



Source: Mokdad A H, et al. J Am Med Assoc 2000;284:13

No Data <10% 10%-14% 15-19% 20%



Source: Mokdad A H, et al. J Am Med Assoc 2001;286:10

No Data <10% 10%-14% 15-19% 20%

Prevalence of Overweight Among U.S. Boys and Girls by

Race/Ethnicity, Ages 6-11, 1963-2000

0

5

10

15

20

25

30

35

40

1963-70

1971-74

1976-80

1988-91

1999-2000

Year of Survey

Prevalence (%)

Black BoysBlack GirlsWhite BoysWhite Girls

Overweight defined as a BMI at the 85th percentile or higher (for age and sex)Troiano RP et al. Arch Pediatr Adolesc Med 1995;149:1085-1091. Ogden et al. JAMA 2002;288:1728-32.

Causes of the Obesity Epidemic

Obesity Fundamentals

• Obesity is caused by excess Energy Intake over Energy Expenditure

• Daily imbalance is on average small: lots of small seemingly inconsequential acts add up to a difficult problem over time - the “fat ratchet”

• Individual behaviors are strongly influenced by their context

Koplan JP,Dietz WH. Caloric imbalance and public health policy. JAMA. 1999;282:1579-81.

The Important Forces: • Food producers and the "Fast Food"

industry - if they’re successful, we all eat more

• Advertisers for food and video/film industries - if they’re successful, we all buy more

• Television and video/film production and distribution industry - if they’re successful we all watch more

The growth of the fast food industry and increasing

portion sizes make it easy for children to overeat

Ebbeling CB, Pawlak DB, Ludwig DS.

Childhood obesity: public health

crisis, common sense cure. Lancet

2002;360:473-82.

“A large fast food meal (double cheeseburger, french fries, soft drink, desert) could contain 2200 kcal, which…would require a full marathon to burn off”

Sugar-sweetened beverages contribute to childhood

obesity incidence

Change in BMI (kg/m2)

Odds Ratio of Obesity

Mean C.I. P OR C.I. P

Baseline Consumption (per 1 serving/d)

.18 .09 – .27 .02 1.5 .6 – 3.5 ns

Change in Consumption (per 1 serving/d increase)

.24 .1 - .39 .03 1.6 1.1 – 2.2 .02

Adjusted for baseline measures of obesity, demographics, school, physical activity, TV viewing, dietary fat, and fruit juice and total energy intakeLudwig DS, Peterson KE, Gortmaker SL. Lancet 2001, 357:505-8

Soft Drink Consumption & Obesity

A Longitudinal Observational Study: Results

0100200300400500600700

1965 1977 1989 1996

Soda Fruit Juice Milk

1965 1977 1989 1996

Con

sum

pti

on (

ml/

d) Boys Girls

Trends in Beverage Consumption Among US Adolescents, USDA 1965-96

Cavadini et al. Arch Dis Child 2000

Television Viewing and Energy Balance: The Science

• A relatively new construct and focus of research

• How can television viewing cause obesity?

• Evidence in support of hypothesis

Hypothesized Impact of Television Viewing on Obesity

ObesityTelevisionViewing

DietaryIntake

Inactivity

Evidence for the Impact of Television Viewing on Obesity

Population-Based Epidemiological Data


Population-Based Epidemiological Data

13 studies in United States

9 studies in other countries

Prevalence of Obesity by Hours of TV perDay; NHES Youth Aged 12-17 in 1967-70

and NLSY Youth Aged 10-15 in 1990

05

10152025303540

0-1 1-2 2-3 3-4 4-5 5 or more

TV Hours Per Day (Youth Report)

Prevalence (%)

NHES 1967-70NLSY 1990

Dietz WH, Gortmaker SL. Do we fatten our children at the tv set? Obesity and television viewing in children and adolescents. Pediatrics, 1985; 75:807-812.Gortmaker SL, Must A, Sobol AM, Peterson K, Colditz GA, Dietz WH. Television viewing as a cause of increasing obesity among children in the United States, 1986-1990. Archives of Pediatrics and Adolescent Medicine, 1996;150:356-362.


Randomized Controlled Trials

Randomized Controlled Trials: Television and Obesity

• School-based intervention: primary grades; impact on mean BMI (Robinson. JAMA.1999. )

• Clinical Intervention: Obese children and youth; impact of reducing inactivity on overweight (Epstein et al. Health Psychol. 1995; Arch Pediatr Adolesc Med.2000;154:220-226.)

• School-based intervention; middle school; reduced television predicts reduced obesity among girls (Gortmaker et al. Arch Pediatr Adolesc Med. 1999)

Planet Health

• Steven Gortmaker, PhD PI

• Karen Peterson, RD, ScD Co-PI

• Jean Wiecha, PhD Project Director

• Nan Laird, PhD Co-Investigator

Carter J, Wiecha J, Peterson KE, Gortmaker SL. Planet Health. Champaign, Illinois: Human Kinetics Press, 2001.

Behavioral Targets

• Reduce TV viewing to less than two hours per day

• Decrease consumption of high fat/saturated fat foods

• Increase moderate and vigorous activity

• Increase consumption of fruits and vegetables to five-a-day or more

Effects of Planet Health

• Obesity among females in intervention schools was reduced compared to controls (OR 0.48; P=0.03)

• Reductions in TV; both boys & girls• Among girls, each hour of TV => reduced obesity (OR

0.86/hour; P=0.02)• Increases in fruit and vegetable intake and less increment in

total energy intake among girls (P=0.003 and P=0.05)

• Gortmaker SL, Peterson K, Wiecha J, Sobol AM, Dixit S, Fox MK, Laird N. Reducing obesity via a school-based interdisciplinary intervention among youth: Planet Health. Archives of Pediatrics and Adolescent Medicine. 1999;153:409-18.

Intervention Impact by School

• Females: evidence for intervention impact in 4 of 5 schools. If the one ineffective site is dropped, intervention effect on obesity is: OR 0.31; P=0.0002

• Males: if the same school is dropped, intervention effect on obesity is OR 0.70; P=0.05

Change in Obesity by Ethnic Group

• Females: evidence for intervention impact by ethnic group – Afro-American (OR 0.14; 95% CI 0.04-0.51) – White (OR 0.48; 95% CI 0.20-1.13)– Hispanic (OR 0.38; 95% CI 0.03-5.3)

Safety: Females

- Evidence for lower incidence of disordered eating behaviors among girls in intervention schools

- Among nondieting girls, onset of these behaviors was 11 times more likely in control versus intervention schools (odds ratio: 10.9; 95% confidence interval: 1.1, 112)

Austin SB, Field AE, Gortmaker SL, 1992. Abstract; Academy for Eating Disorders

The Consequences?

• Clear evidence for increasing risk of cardiovascular disease, diabetes, adult obesity and other morbidities

• But we don’t really know the magnitude: never before have our children and youth been so overweight (and we don’t understand all consequences for adults either)

Freedman DS, Dietz WH, Srinivasan SR, Berenson GS . The relation of overweight to cardiovascular risk factors among children and adolescents: the Bogalusa Heart Study. Pediatrics 1999 Jun;103(6 Pt 1):1175-82

Must A, Spadano J, Coakley EH, Field AE, Colditz G, Dietz WH. The disease burden associated with overweight and obesity. JAMA. 1999 Oct 27;282(16):1523-9.

Growth in Physical Size (Weight) of the Population

• The growing relative weight of the US population has other consequences beyond health (excess morbidity, mortality and quality of life)

– need for larger: clothes, cars, seats on public transportation, home furnishings etc

– need for more food intake to sustain weight (given a constant level of physical activity), thus

– a growing demand for food (growing your market)

Can the Epidemic be Halted?

• Limited evidence for efficacy of treatment of obesity

• The causes of the epidemic are rooted in the success of The causes of the epidemic are rooted in the success of

the food, television/video/movie/game and advertising the food, television/video/movie/game and advertising

industries. These industries are unlikely to change. industries. These industries are unlikely to change.

Why should they when they can make money and Why should they when they can make money and

continue to increase the size of their market?continue to increase the size of their market?

• Some first steps?Some first steps?

Source: Ebbeling CB, Pawlak DB, Ludwig DS. Childhood obesity: public health crisis, common sense cure. Lancet 2002;360:473-82.

Programs, Interventions and Programs, Interventions and ResourcesResources

Bonnie A. Spear, PhD, RDBonnie A. Spear, PhD, RD

Associate Professor PediatricsAssociate Professor Pediatrics

University of Alabama at BirminghamUniversity of Alabama at Birmingham

SchoolsSchools

• School nutrition/PE environmentSchool nutrition/PE environment

• Food venues Food venues

• Physical activity opportunitiesPhysical activity opportunities

School Health Programs and School Health Programs and Policies Study (SHPSS 2000)Policies Study (SHPSS 2000)

J. School Health, vol 71, 7,2001J. School Health, vol 71, 7,2001

• 76% of high schools, 64% of middle schools 76% of high schools, 64% of middle schools and about 50% of elementary schools offer and about 50% of elementary schools offer hamburgers, pizza, other ala carte items at hamburgers, pizza, other ala carte items at lunchlunch

• 13% of schools offer name brand fast foods13% of schools offer name brand fast foods


Vending Machines:Vending Machines:

Accessible by students in 26% elementary, 62% Accessible by students in 26% elementary, 62% middle and 95% high schoolsmiddle and 95% high schools

Most foods high in added fats, sugar and Most foods high in added fats, sugar and sodiumsodium

54% of the schools contracting with soft drink 54% of the schools contracting with soft drink companiescompanies79% received % of proceeds79% received % of proceeds63% received cash and/or school supplies63% received cash and/or school supplies


% of School Districts% of School Districts::Requiring fruit/veggies on ala carte line 20%Requiring fruit/veggies on ala carte line 20%

But…But…90% of the schools offered fruits and 90% of the schools offered fruits and

vegetablesvegetables48% offered low-fat yogurt, low-fat cookies or 48% offered low-fat yogurt, low-fat cookies or

low-fat pastrieslow-fat pastries

Do prices make a Do prices make a difference?difference?

Food Baseline Low price

Post intervention

Fruit

(pieces)

14.4 63.3 26.1

Carrots

(packets)

35.6 77.6 42.0

Salads 14.6 16.0 16.0

JADA 97,1997

What about vending What about vending machines?machines?

• Low fat foods identified by orange dotLow fat foods identified by orange dot• After 4 weeks, prices were reduced by After 4 weeks, prices were reduced by

50%50%• During the price intervention purchases During the price intervention purchases

of low fat food increased by 80% from of low fat food increased by 80% from 25.7% to 45.8% of total sales25.7% to 45.8% of total sales

• Purchases returned to baseline when Purchases returned to baseline when prices were returned to normalprices were returned to normal

AJPH 87, 1997

Problems with PricingProblems with Pricing

• SustainabilitySustainability

• Potential loss of revenuePotential loss of revenue

• Alternate pricing of popular foodsAlternate pricing of popular foods

• Finding other revenue sourcesFinding other revenue sources

Physical Activity in YouthPhysical Activity in Youth

• Nearly half of American youth 12-Nearly half of American youth 12-21 years of age are not vigorously 21 years of age are not vigorously active on a regular basisactive on a regular basis

• Physical activity declines with age Physical activity declines with age from childhood into adulthoodfrom childhood into adulthood


• 16% of high schools required students to 16% of high schools required students to take PE classestake PE classes

• Requirements fall steadily as grade Requirements fall steadily as grade increasesincreases 54% require 154% require 1stst graders to enroll in PE graders to enroll in PE 26% require 726% require 7thth graders to enroll in PE graders to enroll in PE 5% require 125% require 12thth graders to enroll in PE graders to enroll in PE

Percentage of Students Enrolled in Percentage of Students Enrolled in Physical Education Class, by GradePhysical Education Class, by Grade

NCYFS (1984, 1986)

YRBS 1997

NCYFS = National Child and Youth Fitness Study YRBS = National Youth Risk Behavior Survey

Key Components of School & Key Components of School & Community InterventionsCommunity Interventions

• Culturally and linguistically sensitiveCulturally and linguistically sensitive Incorporate cultural values: eating, physical Incorporate cultural values: eating, physical

activity, health, family, communityactivity, health, family, community

• Comprehensive curriculumComprehensive curriculum Address at least two of the following:Address at least two of the following:► NutritionNutrition► School MealsSchool Meals► Health EducationHealth Education

► Physical ActivityPhysical Activity► Sedentary ActivitySedentary Activity► Behavior ModificationBehavior Modification

• ConvenientConvenient

• Low CostLow Cost

• Easily AccessibleEasily Accessible

Available to all youthAvailable to all youth Overweight children are not Overweight children are not

stigmatizedstigmatized

Key Components of School & Key Components of School & Community InterventionsCommunity Interventions

School-Based ProgramsSchool-Based Programs

• Results of school-based interventions include:Results of school-based interventions include: Reductions in hours of TV watched per weekReductions in hours of TV watched per week Increased frequency and duration of physical Increased frequency and duration of physical

activity activity Decreased intakes of total and saturated fatsDecreased intakes of total and saturated fats Increased consumption of fruits and Increased consumption of fruits and

vegetablesvegetables Reductions in rate of increase in BMI Reductions in rate of increase in BMI

percentilepercentile Improved blood lipid levels Improved blood lipid levels

Community-Based ProgramsCommunity-Based Programs

awareness of health risks of overweight awareness of health risks of overweight & importance of a healthy lifestyle& importance of a healthy lifestyle Policy changes related to school mealsPolicy changes related to school meals

• Environmental changes that support good Environmental changes that support good eating and physical activity behaviorseating and physical activity behaviors More walking paths, bicycle lanes, sidewalksMore walking paths, bicycle lanes, sidewalks Increased availability of low fat, nutritious snack Increased availability of low fat, nutritious snack

foods in cafeteria, vending machines, storesfoods in cafeteria, vending machines, stores

Program Grade level

Physical and/ or Sedentary

activity

Food Service and/or

Nutrition

Behavior Modification

Healthy Start Preschool Both Nutrition X

TAKE 10! K - 5 Both Nutrition X

CATCH K - 5 Both Both X

SPARK K - 5 Both Nutrition X

Pathways 3 – 5 Both Both X

Planet Health 6 - 8 Both Nutrition X

Healthy StartHealthy Start• Grade/Age - Grade/Age - Pre-K Pre-K 3 & 4 yrs3 & 4 yrs

Significant decreases in blood lipidsSignificant decreases in blood lipids Increased nutrition and health Increased nutrition and health

knowledgeknowledge Decreased fat and saturated fat Decreased fat and saturated fat

content of preschool meals and content of preschool meals and snackssnacks

www.healthy-start.comwww.healthy-start.com

• Grade/Age: K-5Grade/Age: K-5thth grade grade Reduced sedentary behavior during Reduced sedentary behavior during

school day-increase in moderate to school day-increase in moderate to vigorous activityvigorous activity

Integrated short periods of PA into Integrated short periods of PA into classroom timeclassroom time

75% of teachers felt this was an 75% of teachers felt this was an excellent addition to classroom timeexcellent addition to classroom time

Sustained one year later in 60-80%Sustained one year later in 60-80%www.take10.netwww.take10.net

TAKE 10!TAKE 10!®®

PathwaysPathways• Program: Program:

Grade/Age: Grade/Age: Grades 3-5, American Grades 3-5, American IndianIndian children children

school-based intervention to prevent obesityschool-based intervention to prevent obesity• OutcomesOutcomes

Introduced American Indian children to Introduced American Indian children to variety of PAvariety of PA

Introduce and reinforced healthful eating Introduce and reinforced healthful eating through increasing variety of foodsthrough increasing variety of foods

All curriculums available on-line at All curriculums available on-line at Http://hsc.umn.edu/pathwaysHttp://hsc.umn.edu/pathways

Harvard University Obesity Harvard University Obesity Reduction ProgramsReduction Programs

• Increased fruit & veg intakeIncreased fruit & veg intake• Decreased total & sat. fatDecreased total & sat. fat• Increased mod.-to-vig. physical activityIncreased mod.-to-vig. physical activity• Decrease television viewingDecrease television viewing • Reduction in the prevalence of obesity- felt Reduction in the prevalence of obesity- felt

secondary to decrease TV timesecondary to decrease TV [email protected]@hkusa.com

Planet Health6th & 7th grades

Eat Well & Keep Moving

4th-5th grades

GEMSGEMSGirls Health Enrichment Multi-Site ProgramGirls Health Enrichment Multi-Site Program

Target: 8-10 year old AA femalesTarget: 8-10 year old AA femalesOutcome:Outcome:

increased overall levels of PAincreased overall levels of PAincreased consumption of fruits and increased consumption of fruits and vegetablesvegetablesDecreased consumption of high-fat foodsDecreased consumption of high-fat foods

sss.bsc.gwu.edu/gemssss.bsc.gwu.edu/gems

Studies of Weight LossStudies of Weight Lossin Childrenin Children

6 to 12 years old6 to 12 years old20 – 100% above ideal body weight20 – 100% above ideal body weight

• Implement Implement 6 month program6 month program of behavior of behavior modification to improve diet and activitymodification to improve diet and activity

• 10 year follow-up10 year follow-up 34%34% had at least a 20% weight decreasehad at least a 20% weight decrease 30% 30% were not obese (<120% ideal weight)were not obese (<120% ideal weight)

Epstein, Health Psychology 1994Epstein, Health Psychology 1994

Ten Year Follow-upTen Year Follow-up

0

10

20

30

40

50

60

70

Baseline 8 mon 21 mon 60 mon 120 mon

Control C C + P

0

10

20

30

40

50

60

70

Baseline 8 mon 21 mon 60 mon 120 mon

Control C C + P

% O

verw

eigh

t

Epstein, JAMA 1990

Key Components of Group Key Components of Group ProgramsPrograms

• Healthy eatingHealthy eating• Increased activityIncreased activity• Behavior modificationBehavior modification• Family-based changeFamily-based change• Interdisciplinary teamsInterdisciplinary teams

Physicians, dietitians/nutritionist, exercise Physicians, dietitians/nutritionist, exercise personnel, and behavioral counselors. personnel, and behavioral counselors. Some provide cooking demonstrations.Some provide cooking demonstrations.

ShapedownShapedown™™

Program:Program:

• Enhance self-esteem, adopt healthy Enhance self-esteem, adopt healthy habits, normalize weighthabits, normalize weight

OutcomeOutcome

• Weight loss gradual Weight loss gradual

• Effective at 10 year follow-upEffective at 10 year [email protected]@aol.com

KidShapeKidShape®®/KinderShape/KinderShape®®

Program:Program:• Two 4-week modules for 6-14 yearsTwo 4-week modules for 6-14 years• 6-week program for parents of 3-5 year 6-week program for parents of 3-5 year

olds olds OutcomeOutcome• 87% of families lost weight, 80% kept if 87% of families lost weight, 80% kept if

off for 2 yearsoff for 2 [email protected]@kidshape.com

Committed to KidsCommitted to Kids®®

ProgramProgram• 4 10-weeks sessions (severe, moderate, mild, 4 10-weeks sessions (severe, moderate, mild,

and maintenance) and maintenance) • 6-18 years of age6-18 years of ageOutcomeOutcome• significant decrease in body weight, body fat significant decrease in body weight, body fat

and BMI found in 62.5% who completeand BMI found in 62.5% who complete• 1 year success rate of 70-75%1 year success rate of 70-75%www.committed-to-kids.com/home.htmlwww.committed-to-kids.com/home.html

LESTERLESTER®®

(Let’s Eat Smart Then Exercise (Let’s Eat Smart Then Exercise Right)Right)

ProgramProgram• Dietitian-led, 8-week program Dietitian-led, 8-week program • 6-11 years of age6-11 years of age• Combination of individual and group sessionsCombination of individual and group sessions

OutcomeOutcome• Sign. Decrease in anthropometricSign. Decrease in anthropometric• Decrease in caloric and % fat intakesDecrease in caloric and % fat [email protected]@chsys.org

Programs Based in Programs Based in Primary Care OfficesPrimary Care Offices

• Evaluated ProgramsEvaluated Programs

• Programs Under DevelopmentPrograms Under Development

““Healthy Habits”Healthy Habits”

• Office-initiated weight control for adolescentsOffice-initiated weight control for adolescents

• Computer assessment of behaviors and Computer assessment of behaviors and guidance of behavior changeguidance of behavior change

• One meeting with physician to finalize plansOne meeting with physician to finalize plans

• Weekly calls with counselors, then biweeklyWeekly calls with counselors, then biweekly

Saelens BE. Obes Res 2002;10:22

““Healthy Habits” OutcomesHealthy Habits” Outcomes

5052545658606264666870

Baseline 4 months 7 months

Healthy Habits Physician Care

% O

verw

eig

ht

Saelens BE. Obes Res 2002;10:22

PACE +PACE +

• Computer based counseling in MDs Computer based counseling in MDs offices, targetingoffices, targeting Moderate PA*Moderate PA* Vigorous PA*Vigorous PA* Dietary fats*Dietary fats* Fruit and Vegetable intake*Fruit and Vegetable intake*

**subject chooses area to work onsubject chooses area to work on

• ResultsResults Individuals who use the PACE+ system Individuals who use the PACE+ system

significantly improved “targeted” behaviors significantly improved “targeted” behaviors more than non-targeted behaviorsmore than non-targeted behaviors

Highly rated by all participants as useful Highly rated by all participants as useful informationinformation

Health Partners: Health Partners: 10,000 steps10,000 steps

• Targeted to adults 35-50 who are interested Targeted to adults 35-50 who are interested in becoming more physically active.in becoming more physically active. ComponentsComponents

• PedometerPedometer

• Average StepsAverage Steps Average inactive person 2,000-4,000 steps/dayAverage inactive person 2,000-4,000 steps/day Average moderately active- 5,000-7,000 steps/dayAverage moderately active- 5,000-7,000 steps/day 10,000 steps the equivalent to 5 miles/day10,000 steps the equivalent to 5 miles/day

ResultsResults

• 69% increase in the 69% increase in the number of steps number of steps during the first 8 during the first 8 weeksweeks

• 31% reached the 31% reached the goal of 10,000 steps goal of 10,000 steps

• 50% did not reach 50% did not reach goal, but felt level of goal, but felt level of activity had improvedactivity had improved

4837

71708178

0100020003000400050006000700080009000

1st Qtr

startweek 1week 8

Other studiesOther studies

• Study of overweight, diabetic patients Study of overweight, diabetic patients showed that:showed that: Patients increased to >10,000 steps/d and Patients increased to >10,000 steps/d and

approached 19,000 steps/dayapproached 19,000 steps/day With activity there was significant weight loss With activity there was significant weight loss

and improved insulin sensitivityand improved insulin sensitivityDiabetes Care: 18:775-778,1995.Diabetes Care: 18:775-778,1995.

• No studies in kidsNo studies in kids

Programs Under Programs Under DevelopmentDevelopment

• PROS: Pediatric Research in PROS: Pediatric Research in Office SettingsOffice Settings

• Kaiser Permanente: Kaiser Permanente: A.I.M.A.I.M. for a for a Healthy WeightHealthy Weight

PROS Pilot: RandomizedPROS Pilot: Randomizedcontrolled trial of office practicescontrolled trial of office practices

• Target population: 3 to 7 year olds at Target population: 3 to 7 year olds at risk for obesityrisk for obesity

• Intervention: guidance about healthy Intervention: guidance about healthy activity and eatingactivity and eating

• Outcome at two years:Outcome at two years:

1. BMI percentile 1. BMI percentile

2. Eating and activity behavior2. Eating and activity behavior

AADVISEDVISE All Children/families about All Children/families about healthy behaviors and healthy behaviors and

weightweight

IIDENTIFYDENTIFY Children at Risk (BMI 85-Children at Risk (BMI 85-95%) or OW (BMI >95%)95%) or OW (BMI >95%)

MMOTIVATEOTIVATE Families to make behavior Families to make behavior changeschanges

Kaiser Permanente Message…Kaiser Permanente Message…

A.A.I.I.M. M. for Healthy Weightfor Healthy Weight

Future Goals: Future Goals: Health Care ProgramsHealth Care Programs

• Evaluation and dissemination of Evaluation and dissemination of program outcomesprogram outcomes Short term and long term BMI changesShort term and long term BMI changes Health behaviorsHealth behaviors Emotional/psychological/functional changeEmotional/psychological/functional change

• Matching programs to patientsMatching programs to patients

• Help for the primary care providerHelp for the primary care provider

How Are the Nation’s Schools Doing in Promoting Physical Activity and Healthy Eating?

Howell Wechsler, Ed.D, MPH

Division of Adolescent and School Health

July 2003

State Mandates for Physical Education

• 48 states have some kind of mandate for PE

• # states requiring daily PE, K-12: 1

• # states requiring daily PE, K-8: 1

• High school: majority of states require 1 year or less of PE

Physical Education Requirements by Grade

40

51 51 51 52 50

3226 25

1310

6 5

0

10

20

30

40

50

60

K 1st 2nd 3rd 4th 5th 6th 7th 8th 9th 10th 11th 12th

Per

cen

t o

f sc

ho

ols

Source: CDC, School Health Policies and Programs Study 2000

Daily Physical Education for All Students

• Daily PE or its equivalent* is provided for entire school year for students in all grades in:

8% of elementary schools (excluding kindergarten)

6% of middle/junior high schools

6% of senior high schools

*Elementary schools: 150 minutes / week; secondary schools: 225 minutes / week


Source: CDC, National Youth Risk Behavior Survey

Percentage of U.S. High School Students Who Attended Physical Education Classes Daily,

1991 - 2001

32%29%27%25%

34%

42%

0

10

20

30

40

50

60

1991 1993 1995 1997 1999 2001

Per

cen

t

Percentage of Schools* in Which Required Physical Education is Taught Only by Physical Education Teachers

• Elementary schools: 70%

• Middle/junior high schools: 64%

• Senior high schools: 61%

*Among the 96% of schools that require physical education


After School Physical Activity Programs

• 49.0% of schools offer intramural activities or physical activity clubs for students.

Among these schools, 14.7% provide transportation home for students who participate.

• 99.2% of co-ed middle/junior and senior high schools offer interscholastic sports.


33

91

59 5852

41

0

20

40

60

80

100

Calories Protein Vitamin A Vitamin C Calcium Iron

Percent of RDA

Target

For

Lunches:

33%

Source: School Nutrition Dietary Assessment Study-II (School Year 1998-99)

NSLP Lunches Provide One-Third or More of the Daily RDA

34

12

15

38

0

5

10

15

20

25

30

35

40

Total Fat Saturated Fat

SY 1991-92

SY 1998-99

Pe

rce

nt

of

Cal

ori

es

Target: 30% or less

Target: less than

10%


School Lunches Are Now Significantly Lower in Fat

Percent of Schools Meeting the Fat and Saturated Fat Standards for Lunches Offered

1% 0%

15%

18%

Fat Saturated Fat

1% 0%

22%

17%

Fat Saturated Fat

Elementary Schools Secondary Schools

School Year 1991-92 School Year 1998-99


Average Distribution of School* Milk Orders, by Type of Milk

• Whole milk: 22%

• 2% reduced-fat milk: 41%

• 1% low-fat milk: 28%

• Skim milk: 8%

*Among the 63% of schools in which milk is ordered at the school level

52% of all milk ordered is chocolate or flavored


Certification and Training ofFood Service Coordinators

• Certification for district-level food service directors: 18% of states offer and 6% require

• 60% of districts and 52% of schools have certified food service coordinators

• 40% of district food service directors and 14% of school food service managers have undergraduate degrees


USDA’s Competitive Foods Regulations

• Prohibits sale of “foods of minimal nutritional value” (i.e., soda, water ices, chewing gum, and certain candies) in food service area during meal periods.

• “Foods of minimal nutritional value” does not include many popular snacks high in fat, added sugar, or sodium (e.g., potato chips, chocolate candy bars, donuts, juice drinks).

• States, districts and schools are authorized to impose additional restrictions on the sale of all foods at any time throughout the school.

State Competitive Foods Policies

• 32 states have no regulations beyond USDA regulations

• 2 states have established nutrition standards

• 4 states prohibit or limit food and beverage sales in elementary schools

• Other states limit times when students can buy competitive foods or foods of minimal nutritional value

http://www.fns.usda.gov/cnd/Lunch/CompetitiveFoods/state_policies_2002.htm

Foods and Beverages Commonly Offered a la Carte

• Fruits or vegetables: 74% of schools

• 100% fruit or vegetable juice: 63%

• High-fat baked goods: 59%

• Pizza, hamburgers, or sandwiches: 56%

• Soda pop, sports drinks, or fruit drinks: 32%


Student Access to Competitive Foods and Beverages in Schools

Schools with vending machines or a school store

Elementary Schools: 43%

Middle Schools: 74%

Senior High Schools:

98%


Types of Foods Available in School Vending Machines or Stores*

• High-fat salty snacks: 64% of schools

• High-fat baked goods: 63%

• Low-fat salty snacks: 53%

• Non-chocolate candy: 52%

• Chocolate candy: 47%

• Fruits or vegetables: 18%

*Among the 61% of schools with a vending machine or store


Types of Beverages Available in School Vending Machines or Stores*

• Soft drinks, sports drinks, fruit drinks: 76% of schools

• 100% fruit juice: 55%

• Bottled water: 49%

• Vegetable juice: 13%

*Among the 61% of schools with a vending machine or store


School-Level Requirements for Instruction

797577Physical activity

878185Nutrition and dietary behavior

Senior high schools

Middle schools

Elementary schools


Median Number of Hours of Instruction

543Physical activity

545Nutrition and dietary behavior

Senior high schools

Middle schools

Elementary schools


SHPPS 2000 Reports

http://www.cdc.gov/shpps

Methods

• Representative state-wide samples of middle and senior high schools

• Conducted during even-numbered spring semester

• Separate questionnaires for principals and lead health education teachers

• Questionnaires are self-administered and mailed to participants

Nutrition Topics

• Amount of time for lunch

• Policies on requiring availability of fruits and vegetables

• Student access to 9 different types of foods and beverages in vending machines or school stores

• Nutrition education topics taught

Physical Activity Topics

• PE requirements and exemptions

• Use of physical activity as punishment

• PE teacher certification requirements

• Intramural opportunities

• Use of facilities for community programs

• Topics taught in health education

How Are the Nation’s Schools Doing in Promoting Physical Activity and Healthy Eating?

Howell Wechsler, Ed.D, MPH

Division of Adolescent and School Health

July 2003

Maternal and Child Health Bureau

Question and AnswerSession

maternal and child health bureau seminars on adolescent health: nutrition and physical activity,...

Documents

school health policies

school lunches

school level

pe slide

high school students

fat slide

percentage of schools

nations schools